Using Technology to Improve Health

Research Scientists Study the Intersection of Technology and Health

How does technology change the practice of medicine? Does it create more or fewer patient visits? Can it prevent adverse events or help patients manage their chronic conditions better? These are just a few of the questions researchers and clinicians at the Division of Research (DOR) and Kaiser Permanente Northern California (KPNC) are exploring through a robust technology research program that aims to determine the benefits and potential drawbacks of technology.

"Part of technology research is seeking to understand the consequences of technology and part of it is harnessing it for new uses," says Joe V. Selby, MD, MPH, director of the DOR. He points to diverse research projects underway, including studies that examine the ways in which Web-based programs help patients better manage conditions such as bipolar disorder and others that look at population management tools for improving care for the chronically ill.

Selby credits Kaiser Permanente's electronic health record system, KP HealthConnect™, for making much of this research possible, and, of course, Morris Collen, MD, founding director of the DOR, and a pioneer in medical informatics. KP has been heralded as the vanguard in health care technology for creating the largest civilian electronic health record system in the nation, which includes all of its 8.7 million members, 3.4 million of whom reside in Northern California.

"Technology and the electronic health record are particularly useful in that they allow us to look at populations of patients who meet very complex sets of descriptive requirements," says Selby. "In turn, this allows us to do research that we couldn't do before."

Managing Chronic Conditions Over the Internet

In 2000, Acting Associate Director Enid M. Hunkeler, MA, Joseph F. Terdiman, MD, PhD, director of information technology, and Yvonne Porterfield, RN, MSN, led a team of clinicians, researchers, and consumers to develop and evaluate two interactive, Internet-based care management programs for those with recurrent depression or bipolar disorder.

Enid M. Hunkeler, MAeCare for Moods (patent pending), aims to improve a patient's ability to manage his or her moods, enlist the aid of a care partner, and keep in regular contact with mental health providers, says Hunkeler. She and William A.Hargreaves, PhD, conducted a randomized trial to evaluate the programs. The findings were promising.

Among other things, eCare for Moods allows patients to monitor their personal symptoms and early warning signs, daily functioning, and medication adherence and side effects. Program patients receive education, 24/7 advice, personalized action and emergency plans, and have regular online exchanges with a psychiatric nurse who monitors the Web site daily, says Hunkler. "The program uses information from consumers to individualize care, update symptom profiles, add new coping strategies, and automatically alert the nurse when a patient needs help."

Following the success of eCare for Moods, eCare for Health was developed and beta tested. This Internet-based program helps patients manage their diabetes and provides primary care physicians with evidence-based treatment recommendations for individual patients. Patients can enter their blood sugar and blood pressure numbers at anytime and receive online clinical assessments and advice on next steps.

"Both eCare programs significantly advance our patients' abilities to manage their conditions and to communicate quickly and easily with clinicians," says collaborator Robin Dea, MD, Kaiser Permanente Northern California regional director, mental health services.

Improving Diet and Physical Activity Through E-mail

Similarly, the ALIVE (A Lifestyle Intervention Via E-mail) program, led by Barbara Sternfeld, PhD, seeks to promote physical activity and healthy eating using e-mail and a Web-based tool.

Developed in the fall of 2006, the yearlong ALIVE program was offered to KPNC regional employees and included a randomized controlled study in which half of the group received 12 individually tailored e-mail messages about healthy food and lifestyle choices. The intervention group had a personal Web page and was measured on physical activity and dietary changes.

"The results were very positive. We saw improvements in all measures," says Sternfeld, noting that publication is pending. Overall, she says, compared to the control group, employees in the intervention group increased on all measures of physical activity, while showing a drop in sedentary behavior. Furthermore, the intervention group ate less saturated fats and transfats and more fruit and vegetables.

"We saw the greatest improvement in those who needed to improve the most," says Sternfeld. The program, she adds, has the potential to work well in the work setting because it is offered via e-mail and encourages social support. "The greatest thing about this is that it's very cost effective and can be widely disseminated."

Managing Care for Large Populations

Julie Schmittdiel, PhDOne of the obvious benefits of an advanced information technology system is the clinical data it generates. Yet, having the data in raw form doesn't mean it always gets to the clinician in a way that is useful. "We have huge databases but the question for me is how can we arrange these vast quantities of information in ways that are helpful to the people who use it," says Julie Schmittdiel, PhD.

Schmittdiel and Selby are working to change this through the INFO (Intensification and Feedback of Outcomes) trial, which aims to leverage pharmacy and electronic health record data to improve care for patients with cardiovascular disease.

INFO, a two-year cluster-randomized trial, begun in 2007 and funded by AHRQ, is conducted in collaboration with Kaiser Permanente's Quality and Operations Support (QOS) Department. INFO generates new information and adds it to KP's Panel Management Tool (PMT), a database for patients at high risk of cardiovascular disease. These 300,000 KP patients are part of the PHASE program (Preventing Heart Attacks and Strokes Everyday).

The INFO study processes pharmacy data to calculate medication adherence and identifies patients who are adherent to their medications but need the doses to be modified. INFO research staff place this new information in the PMT and work with staff in intervention facilities to make it useful, notes Schmittdiel. "The INFO study will evaluate whether providing this new information enables PHASE teams in facilities to help more people reduce risk factor levels in the population."

While the study has another year to go, Schmittdiel says if results are positive, the goal will be to offer these tools to all KPNC facilities.

Over the next several years as Kaiser Permanente continues to hone its technology capabilities, the DOR hopes to participate further with operational and clinical leadership in this rich research area.

"When you know things such as a person's medications and lab results, and know it for thousands of people, you have the ability to direct organizational attention to those patients who can benefit the most," says Selby.

"At the same time, we are well positioned to publish our findings because they are based on large numbers of patients, with high-quality data."